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CONIAKACTOR/CONSULTANT QUESTIONMIRE <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388 STOCKTON CA 95201-0388 <br />OWNER INFORMATION <br />BUSINESS NAME: ��iG' ��jt/ �}'I/p,v <br />ADDRESS: jZ7-446-' <br />CITY/STATE/ZIP: �� c,4 9s37� <br />731'-Zf/0 PHONE NO 2 ( ) FAX NO C2�5 ) �3> ff <br />PHONE NO �20f) <br />OWNER ill INFORMATION <br />OWNER #2 INFORMATION <br />NAME: <br />NAME: <br />ADDRESS: <br />ADDRESS: <br />CITY: <br />U <br />CITY: <br />STATE: C ZIP: 9S <br />STATE: ZIP: <br />LICENSE INFORMATION <br />CA CONTRACTOR LICENSE 65).i2,TI DATE ISSUED ,` /2% /�(� EXP DATE/2-0 <br />LICENSE CLASS 1 A LICENSE CLASS 2 LICENSE CLASS 3 <br />"C" SPECIALITY #'S A�4 L1 - <br />TYPES OF LIMITED SPECIALTY(IES) Aq? <br />LICENSE IN GOOD STANDING? o N WORKERS COMP INSURANCE Y" N <br />WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E.H.D.? U N <br />EXPIRATION DATE <br />HAZARDOUS WASTE CLEAN UP CERTIFICATION? lY' N <br />CONSULTING FIRM INFORMATION <br />SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? Y N <br />CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? Y N <br />PRIMARY QUALIFYING INDIVIDUAL: <br />GEO/ENGINEERING REG/CERT NUMBER: <br />